|
Age 14 days to Age 69 |
Age 14 days to Age 69 |
Age 70 and over |
| INPATIENT |
$50,000 Max per Injury / Sickness |
$100,000 Max per Injury / Sickness |
$50,000 Max per Injury / Sickness |
| Hospital Room & Board including miscellaneous |
Up to $1400/day, 30 day max |
Up to $1950/day, 30 day max |
Up to $1050/day, 30 day max |
| Hospital Intensive Care Unit |
Additional $660/day, 8 day max |
Additional $850/day, 8 day max |
Additional $460/day, 8 day max |
| Surgical Treatment |
Up to $3300 |
Up to $5500 |
Up to $2750 |
| Anesthetist |
25% of surgical benefit |
25% of surgical benefit |
25% of surgical benefit |
| Assistant Surgeon |
25% of surgical benefit |
25% of surgical benefit |
25% of surgical benefit |
| Physician's Non-Surgical Visits |
Up to $55/visit, 1/day, 30 visits |
Up to $85/day, 1/day, 30 visits |
Up to $55/visit, 1/day, 30 visits |
| Consultant Physician, when requested by attending Physician |
Up to $450 |
Up to $500 |
Up to $400 |
| Pre-Admission Tests within 7 days before Hospital admission |
Up to $1100 |
Up to $1100 |
Up to $775 |
| Private Duty Nurse |
Up to $550 |
Up to $550 |
Up to $450 |
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|
|
| OUTPATIENT |
|
|
|
| Surgical Treatment |
Up to $3300 |
Up to $5500 |
Up to $2750 |
| Anesthetist |
25% of surgical benefit |
25% of surgical benefit |
25% of surgical benefit |
| Assistant Surgeon |
25% of surgical benefit |
25% of surgical benefit |
25% of surgical benefit |
| Physician's Non-Surgical / Urgent Care Visits |
Up to $55/visit, 1/day, 10 visits |
Up to $85/visit, 1/day, 10 visits |
Up to $55/visit, 1/day, 10 visits |
| Diagnostic X-rays & Lab Services |
Up to $450
Additional $250 - One Cat scan, PET scan or MRI |
Up to $500
Additional $500 - One Cat scan, PET scan or MRI |
Up to $400
Additional $250 - One Cat scan, PET scan or MRI |
| Hospital Emergency Room (all expenses incurred therein) |
75% of U&C to $330 |
75% of U&C to $550 |
75% of U&C to $250 |
| Prescription Drugs |
Up to $100 |
Up to $150 |
Up to $80 |
| Outpatient Surgical Facility |
Up to $1000 |
Up to $1100 |
Up to $850 |
| OTHER TREATEMENT AND SERVICES |
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|
|
| Ambulance Services |
Up to $450 |
Up to $450 |
Up to $450 |
| Initial Orthopedic Prosthesis / brace |
Up to $1100 |
Up to $1300 |
Up to $850 |
| Chemotherapy and / or radiation therapy |
Up to $1100 |
Up to $1300 |
Up to $850 |
| Dental Treatment for Injury to Sound, Natural Teeth |
Up to $550 |
Up to $550 |
Up to $550 |
| Mental & Nervous Disorder & Substance Abuse |
Same as any Sickness |
Same as any Sickness |
Same as any Sickness |
| Physiotherapy |
Up to $40/visit, 1/day, 12 visits |
Up to $40/visit, 1/day, 12 visits |
Up to $40/visit, 1/day, 12 visits |
| Emergency Evacuation |
$50,000 |
$50,000 |
$50,000 |
| Repatriation of Remains |
$7,500 |
$7,500 |
$7,500 |
| AD&D Principal Sum |
$25,000 Common Carrier |
$25,000 Common Carrier |
$25,000 Common Carrier |
Should an insured person turn 70 during the purchased coverage period, the 70 and over benefit schedule becomes effective upon the day the insured turns 70.
